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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
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New procedure for submitting letters

  • Patricia Casey and Jonathan Pimm
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eLetters

Conversion Therapy and the LGBT community: the role of the College now?

annie bartlett, Professor of Offender Healthcare, SGUL
26 July 2018

The history of the relationship between the LGBT community and psychiatry has not been a happy one, reflecting but also at times reinforcing hostile social attitudes. More recently, both psychiatry and psychological therapies have been at pains to distance themselves from previous discriminatory practice and align themselves with more contemporary understandings of diverse sexual identities and behaviour. The College and other bodies such as the UKCP have developed clear statements on sexual orientation and the issue of conversion therapy in particular, pointing out that it does not work, can create distress and should not to be undertaken (UK Council for Psychotherapy, British Psychoanalytic Council, Royal College of Psychiatrists, et al (2014) Conversion Therapy: Consensus Statement. UK Council for Psychotherapy).

This position on conversion therapy is echoed in the raft of 75 measures announced recently by Women and Equalities Minister Penny Mordant, based on the results of the largest survey of LGBT people ever undertaken. The measures are designed to create a more inclusive society, in which, amongst other things, individuals of any sexual persuasion may feel able to hold hands in public without fear of ridicule or attack (Hansard HC Deb, 3 July 2018, cWS). That a conservative government has launched such an initiative seems remarkable to those of us able to remember Section 28 brought in by the Thatcher government 30 years ago (Local Government Act 1988).

But, we should be mindful as a profession that some practitioners may not be so sympathetic to this direction of travel. Not so long ago a significant proportion of psychiatrists and therapists, 4%, were still prepared to to treat individuals for their gay and lesbian identities (Annie Bartlett, Glenn Smith and Michael King The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation BMC Psychiatry 2009 9:11https://doi.org/10.1186/1471-244X-9-11) . It is not clear how much this has changed, if at all, on the ground. Equally, it is still very easy to locate reparative therapy options on the Internet, a common port of call for those wanting some help negotiating same sex sexual preferences. A quick search picks up, amongst others, Nicolosi’s web site which continues to say “If gay doesn't define you you don’t have to be gay” accompanied by claims of treatment efficacy, in line with the views he so publicly expressed until his death in 2017 (https://www.josephnicolosi.com). He recommended reparative therapy, said it worked and should be offered as a psychological therapy. The number of individuals currently involved with reparative therapy is unclear and seems likely to be difficult to establish as recent medical and political pronouncements may well drive it underground.

The College has an international reach. Many countries are still much more punitive to LGBT individuals than the UK; some have the death penalty on their statute books. Major world religions are internally divided on LGBT issues and can legitimise not only adverse social attitudes but also attempts at religious rather than medical cure. It remains to be seen how energetic the College feels it should be in sharing its liberal understanding of sexual preference. Its position on change orientated treatments of any kind has international applicability. There may well be many individuals overseas who would thank psychiatry for taking part in this ongoing debate.

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Conflict of interest: None declared

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Attitudes of Sixth-Form Students to Serious Mental Illness: before, during and following a Mental Health work experience week

Helen Hargreaves, Psychiatry Teaching Fellow, Northumberland, Tyne and Wear NHS Foundation Trust
Rachel Gore, Consultant (Old Age Psychiatry), Northumberland, Tyne and Wear NHS Foundation Trust
24 July 2018

Negative attitudes towards mental health patients are identified as some of the background factors affecting speciality recruitment (1). The highest rate of such negative attitudes is identified in 16-19 year olds (2) where stigma is often associated with beliefs that patients are violent and unpredictable (3,4,5). Work experience placements target this group before they enter medical school and provide an opportunity to favourably influence attitudes. This positive impact has been previously highlighted but its persistence is not clear (3).

Northumberland, Tyne and Wear NHS Foundation Trust offers an annual one-week work experience programme. Twenty-one students took part in the most recent programme and were invited to partake in an evaluation of its impact on attitude. The results offer support for the potential of work experience placements to favourably influence attitudes in both the immediate and longer-term but also highlight key areas for further consideration.

The Attitude Towards Serious Mental Illness Scale–Adolescent Version (ATSMI–AV) is a twenty-one item validated measure of attitude towards mental illness (3,4) and was offered to students at day one, day five and at three months. The individual items correspond to five identified factors: Threat, a fear of harm to someone or reputation; Social Concern, the label of mental illness being controlling and a worry about developing mental illness; Wishful Thinking, a belief that people with mental illness can be cured by trying hard enough or being loved; Categorical Thinking, the idea that people with mental illness can be identified as different; and Out of Control, suggesting that people with mental illness are involved with drugs and violence.(4)

Regarding sustained favourable impact, there was a significant change concerning one factor, Threat. Particularly being less embarrassed if they were diagnosed with a mental illness. One other factor demonstrated a favourable sustained shift - Categorical Thinking. These factors were also found to have had a significant positive shift in a previous study (3) which may suggest that they are readily addressed by work experience placements.

Two factors were negatively influenced at immediate evaluation, Wishful Thinking and Out of Control. However, this was not significant and both factors were then favourably influenced at three months. It may be that there is greater benefit from the consolidation of new learning/attitudes here than is suggested by the immediate evaluation.

Social Concern was favourably influenced at its immediate evaluation but was not sustained, and in fact had worsened at three months. Potential reasons for this were not explored but it may be that this work experience did not adequately address learning needs and as such sustained knowledge regarding this factor was negatively impacted.

The findings summarised here support mental health work experience as an opportunity to favourably influence potential medical student attitudes towards mental illness and highlights the potential to achieve sustained effects. However, the potential for unfavourable effects should also be considered. Those organising work experience placements would benefit from considering the attitude factors relevant here and in seeking to design experiences which will target all areas more favourably.

References

1. Brockington, I. Mumford, D. Recruitment into psychiatry. The British Journal of Psychiatry 2002; 180:307-312.

2. Crisp, A. Gelder, M. Goddard, E. Meltzer, H. Stigmatisation of people with mental illnesses: a follow up study with the Changing Minds campaign of the Royal College of Psychiatrists. World Psychiatry 2005; 4(2):106-113.

3. Kennedy, V. Belgamwar, RB. Impact of work experience placements on school students’ attitude towards mental illness. Psychiatric Bulletin 2014; 38:159-163.

4. Watson, AC. Miller, FE. Lyons, JS. Adolescent attitudes towards serious mental illness. The Journal of Nervous and Mental Disease 2005; 193(11):769-772.

5. Byrne, P. Stigma of mental illness and ways of diminishing it. Advances in Psychiatric Treatment 2000; 6(1):65-72 (http://apt.rcpsych.org/content/6/1/65).

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Conflict of interest: None declared

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Relatives’ knowledge and attitudes to leave from psychiatric inpatient units

Christopher Bu, Foundation Year 2 Doctor, Royal Liverpool & Broadgreen University Hospitals Trust
Indira Vinjamuri, Consultant Psychiatrist, Mersey Care NHS Foundation Trust
25 June 2018

A recent patient suicide took place whilst on leave from an inpatient unit in an inner city psychiatric unit and the coroner concluded that there needed to be better documentation of leave being discussed with relatives. As such we set out to evaluate our current practice. Section 17 of the Mental Health Act does not currently mandate discussion with relatives prior to granting leave and so we present here a survey exploring what relatives know and expect when it comes to leave.

Relatives were approached during hospital visiting hours and asked to complete a voluntary questionnaire. This took place over an 8-week period over four inner city psychiatric wards with relatives being interviewed by a range of staff. The 11-item questionnaire covered 2 themes:

1. Relatives’ knowledge of the process of granting leave.

2. What relatives thought could be improved.

23 questionnaires were completed. Of these, 11 were detained and 10 were informal patients. 2 patients’ MHA statuses were not recorded. Respondents ranged from immediate family members, to close friends. Patient age ranged from 18 to 57 and patients were not discriminated by admission reason or by psychiatric diagnosis.

16 respondents did not know that leave could be granted without a relative first being informed. Surprisingly, 7 respondents were unaware that inpatients were even allowed any leave at all during their admission. None of the 23 relatives had read the ‘Carer’s Pack’, an information resource intended for relatives at the beginning of each admission, nor did it contain the relevant information.

20 respondents expressed that relatives should always be informed when patients are granted leave. 21 respondents felt confident contacting the ward at least with a telephone call if they had any concerns and 19 of these respondents felt that any potential concerns would be listened to by the treating team.

Although this was a small survey, these findings suggest that relatives do not know as much as we may assume they do. Not only were relatives unaware of the leave process, but it was surprising that so many respondents did not know that leave was granted at all. This confirms a real gap in knowledge between teams and relatives. The feeling from relatives was that they wanted to be more involved in decisions around leave, feeling confident in potentially doing so, even if just with a phone call.

Given these findings the trust has introduced a leave proforma into ward reviews, checking the patient’s preferred relative to contact, respecting confidentiality and also working towards the coroner’s recommendation to improve documentation. Teams will also aim to review patients with their relatives at least once during their admission. In addition, the carer’s pack will be better advertised and updated to include clear written information about the inpatient leave process. These changes will work towards bridging the gap between relatives and professionals, not forgetting how much we rely on relative care and support both during and after patients attend an inpatient unit.
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Conflict of interest: None declared

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Maintenance doses for Clozapine: past and present

AVNEET SHARMA, Consultant Psychiatrist, Avon and Wiltshire Mental Health Partnership NHS Trust
19 June 2018

We recently completed a QIP for patients on long term Clozapine with the main aim of assessing the side effect burden with a view to optimise the treatment. We compare our current clinical practice with one described in a publication 20 years ago in Psych bulletin 1998(1) (Murphy et al) on maintenance doses for Clozapine.

Murphy et al⁽¹⁾ presented findings on forty four patients who have been on Clozapine for 6 months or more . Our patient number was Forty one and the information was retrieved from electronic case records though this did not make the job easier as the relevant information was scattered around across time in different sections of the record system.

The patient group in Murphy’s study had a mean age of 38 years (21 to 62 years) with 35 males and nine females, majority being Caucasian with mean duration of Clozapine treatment of 38 months (7-69months). The highest treatment dose prescribed ranged from 300 mg to 900 mg per day (mean 568 mg) with 50% patients on 500 mg per day or less, only one patient received the maximum dose of 900 mg. The current or maintenance doses of Clozapine ranged from 150 mg to 750 mg per day (mean460 mg) with eight patients on doses of 150 and 300 mg per day which was within the then BNF guidelines. British National Formulary (BNF: number 33, March 1997) guidelines at the time clearly differentiated between the higher doses (200-450 mg daily, maximum 900 mg) required initially to stabilise the mental state, and the lower doses (150mg-300 mg daily) required subsequently for maintenance treatment. The authors found that dosage reductions had been achieved in 29 cases while no attempt to reduce the dose in majority of the rest of the patients was due to partial response or less than expected symptom control.

Our group had older patients with a mean age of 44 years (29-70 years) and were predominantly Caucasian y with 30 males and 11 females and mean duration of treatment with Clozapine was more than 10 years (range of 1-30 years). The dose ranged from 200 -900mg per day with mean dose of 405 mg per day; 25 patients were on doses between 300mg -500 mg per day which would have been deemed higher as per BNF guidelines of 1997.

We found that that 80% of patients were reporting significant side effects including drooling, sedation/tiredness, GI Symptoms, weight gain, urinary incontinence, constipation. Also a significant proportion (50%) were on side effects medications generally in combination There were significant metabolic problems with average BMI of 29.40 with most of the patients apart from 5 having BMI above 23; two cases were diagnosed with diabetes and on treatment.

We also found that there has been no reduction in Clozapine doses in any of the cases over at least last 7 years at least including more recent cases. Of course one big difference is that there are no current British National Formulary guidelines for the maintenance doses for Clozapine, BNF(September 2016- March 2017) mentions usual dose range for Clozapine of 200 mg to 450 mg per day that one needs to titrate to while starting clozapine.

The side effect burden on its own should be enough to make clinicians keep dose review on agenda on regular basis. Due to large variations in metabolism it is hard to predict the optimum dose and plasma level in individual patient, the manufactures ⁽²⁾ advise that once maximum therapeutic benefit has been established, many patients can be maintained effectively on lower doses with careful downward titration. The past BNF guidelines regarding maintenance doses were thought to be not based on evidence (1) but empirical; may be it is time to revisit the past as patients appeared to be getting a better deal.

References

1. Bernadette Murphy, Colm Long and Carol Patton- Maintenance doses for clozapine Psychiatry Bulletin

(1998)22, 12-14.

2. Beelen, Van AJ; Jollie-Helthuis M (2013) Zaponex Fact Sheet Clozapine dosing and metabolism

Doc.05.SOP.LNL.600.01 Mar 2013
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Conflict of interest: None declared

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How does current guidance affect the use of long term segregation by forensic psychiatrists in the United Kingdom?

Gareth Garrett, ST5 Forensic Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust
Nicholas Taylor, Consultant Forensic Psychiatrist, Nottinghamshire Healthcare NHS Foundation Trust
18 June 2018

The Mental Health Act Code of Practice 2015 expanded the guidance on restrictive practices such as seclusion and long-term segregation. Recommendations were made regarding the physical conditions within which patients could be segregated, the reporting requirements, and how local policy and procedure should shape practice.1

Guidance around restrictive practice is welcomed, as part of the agenda to reduce these interventions,2,3 however it is accepted that there remain occasions when such measures are necessary.4

It is our experience that long term segregation in particular is used differently by teams even within the same service.

We were curious how familiar clinicians were to the guidance in the 2015 code, how restrictive practices were used in different areas and any relevant impact on clinical practice.

A questionnaire was devised to capture the experience of Consultant Forensic Psychiatrists. It was made available. Links were sent to representatives for forensic psychiatry training schemes in the United Kingdom for wider circulation to colleagues. Data was collected over a period of one month.

There were 25 respondents in total.

There was an equal spread of respondents when asked about their knowledge of the changes to the guidance on long-term segregation. On a five-point Likert scale, 44% identified themselves as confident, with the same number describing themselves as unconfident. One respondent commented that it was necessary to refer back to the Code as long-term segregation was not used often.

Respondents commented that long-term segregation was not clearly defined, and that the guidance around the frequency of review was poor. The requirements around independent reviews were regarded as unclear.

A large majority of respondents said that seclusion was easier to use in their place of work. Over two thirds of respondents said that long-term segregation required more paperwork.

Many barriers for the use of long-term segregation were described. These included the physical security measures required for its safe and appropriate use, and the amount of paperwork required. Despite this, 60% of respondents felt that long-term segregation was valuable to clinical practice.

Long-term segregation remains a useful tool for patients with a history of institutional violence who have spent long periods of time in seclusion. For some patients, long–term segregation may represent the least restrictive environment within which they can be safely managed. Clinicians may be discouraged from using such an intervention due to the nature of ward environments or the necessary reporting requirements.

The results of the survey confirmed anecdotal reports that patients may well be detained in more restrictive conditions (seclusion rather than LTS) because the bureaucratic process around seclusion is easier to navigate. This is a matter of concern and we would urge a review of the Code of Practice and of procedures within mental health providers to ensure that this imbalance is corrected as a priority.

References

1. Department of Health. Mental Health Act 1983: Code of Practice. TSO (The Stationary Office), 2015.

2. Tully J, McSweeney L, Harfield K, Castle C, Das M. Innovation and pragmatism required to reduce seclusion practices. CNS Spectrums 2016; 21(6) 424-429

3. Gaskin C, Elsom S, Happell B. Interventions for reducing the use of seclusion in psychiatric facilities: review of the literature. British Journal of Psychiatry 2007; 191 298-303

4. National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. (NICE Guideline 10) Available at: https://www.nice.org.uk/guidance/ng10/chapter/1-Recommendations#using-restrictive-interventions-in-inpatient-psychiatric-settings-2 [Accessed 06 February 2018]

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Conflict of interest: None declared

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